Cancer Complications

The Attack One crew is finishing a training session on a hot day, hoping to get back to the station to shower and change clothes. But the radio crackles with a request to respond to a “person ill.”

The family is waiting at the door and brings the crew into the bathroom, where a very pale woman is sitting on a closed toilet seat.

“I just feel awful,” she reports. “Yes, ma’am,” the concerned paramedic agrees. “You appear to feel awful.”

And she does: The woman is thin with a washed-out appearance, and has a fresh surgical scar on her abdomen and an empty colostomy bag attached to her abdominal wall. She is slumped over, breathing quickly, and her voice is very soft.

Placing a caring hand on her shoulder, the paramedic asks if he can feel her pulse in her wrist. When he places his other hand on her wrist and attempts it, he can detect no radial pulse.

The other crew members are obtaining vital signs, collecting the woman’s medicines from family members and setting up for intravenous treatment. “What does the pulse oximeter read?” the paramedic asks, thinking he finally feels a weak radial beat. They place a pulse oximeter on her finger, and her pulse is audible at a regular and rapid rate. Her oxygen saturation is in the high 80% range. They check a quick blood pressure and apply an oxygen mask at high flow.

The paramedic directs the EMTs to place the patient on the 3-lead monitor to evaluate the rapid pulse as he interviews her further. The patient speaks so softly, he needs to concentrate on her answers.

The patient is 41 years old and was just diagnosed with an extensive colon cancer. Surgeons removed much of her bowel, and she had a colostomy placed. She’s had significant pain and weakness since her surgery. She was released from the hospital two days prior while the treating physicians set up further treatments. She’s had no appetite and, being unfamiliar with colostomy drainage, can’t tell if she’s lost an unusually large amount of bowel material. The medic begins to question her about losing blood when the EMT calls his attention to the cardiac monitor. It shows the patient is in a rapid wide-complex tachycardia. Her heart rate is about 200 beats a minute.

“We know you’re feeling very weak,” the medic quickly tells the woman, “so we’re going to lift you onto our cot and let you lie down. Your blood pressure is low, and your pulse rate is very high. Have you ever had any heart problems?”

That answer is no, and the crew members lift the woman onto the stretcher. They elevate her legs and look for a site to start an IV in her arms. But the arms are covered in bruises from her time in the hospital, and when asked the patient says the nurses said she “had no veins left.”

The paramedic carefully studies the cardiac monitor. As many ways as he can analyze it, the patient’s rhythm is ventricular tachycardia. But she denies any chest pain and repeats that she’s had no past incidence of heart problems or fast heartbeat.

The paramedic examines her on the stretcher and notices that in Trendelenburg position, her external neck veins are visible. He quickly places a catheter in the right external jugular vein and begins a rapid fluid infusion. Before they leave the bathroom with the stretcher, he checks the closed toilet. “Just making sure the commode isn’t full of blood,” he tells one of the EMTs.

The patient’s husband has brought all her medicines to the crew. No heart medicines are among them, but she is on Coumadin, a blood thinner.

The paramedic calls medical control to explain this complicated patient. They discuss the combination of events: new finding of cancer, big surgery, new colostomy, poor intake, weakness, and a rhythm of v-tach in a conscious patient. The medic and physician agree to give a full liter fluid bolus, and give a bolus of lidocaine and start a drip to try to control the heart rhythm. The crew will transport to the hospital where the surgery took place, meaning a 15- to 20-minute ambulance ride.

The patient tolerates the fluid bolus, and after the 10-minute infusion of lidocaine, her rhythm converts to sinus. Her other symptoms don’t change. The fluid bolus is complete by the time she arrives at the emergency department.

Hospital Management

The patient and her husband are taken into a cardiac room, and the Attack One crew shares her history and rhythm strip. The physician agrees the rhythm was ventricular tachycardia. It stabilized on the lidocaine and fluid, but the potential problems affecting this patient are many.

About 15 minutes after arrival, as the Attack One crew is leaving the ED, the patient’s nurse comes to them and asks if they’ll come back to the patient’s room. There the physician and nurse have the patient’s lab results, which they’re explaining to her and her husband. The tests show a critically low value for potassium, which was the cause of the ventricular tachycardia. She will need immediate replacement of that electrolyte, which has been lost due to the cancer and “short gut” that resulted from her surgery. She is also malnourished and dehydrated, and her bone marrow is not performing well, so her white and red blood cells are low. The immediate life-threatening problem, ventricular tachycardia, will be treated by replenishing the potassium intravenously. It will take more treatment and tests done in concert with the woman’s cancer specialists to manage other problems just being identified.

The patient is admitted and makes a slow recovery.

Customer Service Opportunity

A recent diagnosis of cancer is a traumatic experience for patients and families. There is a period of time for most patients where information about the diagnosis is still being processed, and where surgeries and treatments with radiation and medications are fresh in the mind. Emergency medical events during this time can have a wide range of causes, and the prehospital environment is where most of them can be assessed well. This is one of the important groups of patients with medical needs that are best served at hospitals where their workups and treatments are taking place. That hospital will have complete medical records and access to the team that’s provided the complicated care at the initiation of the cancer.

Learning Point

Digestive failure and a metabolic emergency in a patient with recent diagnosis of colon cancer.

James J. Augustine, MD, FACEP, is medical advisor for the Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and an editorial advisory board member for EMS World. Contact him at jaugustine@emp.com.